Provider Demographics
NPI:1003329194
Name:ROSENBORO, GABRIEL (BS CRIMINAL JUSTICE)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:
Last Name:ROSENBORO
Suffix:
Gender:M
Credentials:BS CRIMINAL JUSTICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 BRAXTON RD
Mailing Address - Street 2:
Mailing Address - City:GRIFTON
Mailing Address - State:NC
Mailing Address - Zip Code:28530-8628
Mailing Address - Country:US
Mailing Address - Phone:919-268-9660
Mailing Address - Fax:
Practice Address - Street 1:4400 OLD POOLE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-3033
Practice Address - Country:US
Practice Address - Phone:919-268-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$Medicaid